Failure to Provide Proper Incontinence Care During Brief Change
Penalty
Summary
A deficiency was identified when a Certified Nurse Aide (CNA) failed to provide appropriate incontinence care to a resident who was dependent on staff for activities of daily living and was incontinent of bowel and bladder. During an observed brief change, the CNA removed a soiled brief and applied a clean one without cleansing or rinsing the resident's perineal area or buttocks, contrary to the facility's perineal care policy. The CNA later acknowledged that she did not provide perineal care during the change and attributed the omission to being nervous during the observation, despite knowing the correct procedure. The resident involved had a diagnosis of Metabolic Encephalopathy, was severely cognitively impaired, and required staff assistance for toileting hygiene. Facility policy required thorough cleaning of the perineal area with soap and water, rinsing, and drying during incontinence care, which was not followed in this instance. The Director of Nursing confirmed that staff are expected to always provide proper incontinence care to prevent infections or skin breakdown.